Vaccinations, One-to-one midwives, Leg ulcers, Asthma inhalers

How would you feel if your child's immunisations were linked to benefits or child care? In Australia, a full set of vaccinations is now a requirement for accessing most types of child care and claiming family tax credit worth around £500 a year. The only exception is if parents ask to be registered as conscientious objectors. Dr Steve Hambleton is President of the Australian Medical Association and explains how well these measures have been received.

University of Sydney researchers have just published a new study adding to a body of evidence that pregnant women who see the same midwife require less intervention, have safer outcomes and are more likely to breastfeed their babies. They also save the healthcare system over £300. Professor Cathy Warwick, chief executive of the Royal College of Midwives, tells Inside Health that adoption of this "caseload" model in the UK has been slow.

Around half a million people in the UK have some form of leg ulcer, and up until recently many would have them dressed in the community for years, without the underlying cause ever being diagnosed and treated. But this now looks set to change, as new guidance published by NICE recommends that if ulcers last more than two weeks, patients should be referred to a specialist vascular clinic. Like the one at Addenbrooke's Hospital in Cambridge, run by consultant vascular surgeon Mr Paul Hayes.

Last year the NHS spent around £800 million on asthma medicines, but research suggests that at least half of people given the most common type of inhaler do not use them properly. This means their asthma remains poorly controlled and the NHS is wasting hundreds of millions of pounds. Mike Thomas is Chief Medical Advisor to Asthma UK.

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Programme Transcript - Inside Health

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

INSIDE HEALTH

Programme 4.

TX: 15.10.13 2100-2130

PRESENTER: MARK PORTER

PRODUCER: ERIKA WRIGHT

Porter

Coming up in today’s programme: Allocating pregnant women a named midwife to oversee their care seems to improve outcomes and cut costs – so when is it going to happen?

I’ll be finding out why a small fortune is being wasted every year on asthma inhalers that people can’t use.

And new guidance from NICE that could transform the lives of the half million people in the UK with leg ulcers.

Clip

The wound actually covered from my knee to my ankle all the way round.

There was no skin there?

No skin at all, no. It was dripping with exudate, it was really wet most of the time…

My legs were like tree trunks, they were huge, for the first two years and I had them bandaged them up and have had them more or less ever since.

I don’t think I’ve ever had pain like it and it kept me awake most nights.

Porter

But first, vaccinations have been making the headlines again following the High Court judgment that two children be given the MMR vaccine against their will, and the wishes of their mother, because it is good for them.

It is an unusual, and extreme example, but far more subtle forms of coercion to boost uptake rates of vaccines like the MMR were raised at at least one of the party conferences last month.

How would you feel if your child’s immunisations were linked to your allowances – no jabs, no benefit? Or were a requirement for care or early education? No jabs – no child-minder and no play group?

Well that is exactly what has happened in Australia where, along with a number of other initiatives to combat worrying low uptake rates, a full set of vaccinations is now a requirement for accessing most types of childcare, and claiming family tax credit worth around £500 a year. The only exception being if parents ask to be registered as conscientious objectors – simply not turning up for your child’s appointment is not an excuse.

So how have the changes gone down?

Dr Steve Hambleton is President of the Australian Medical Association

Hambleton

Actually they were surprisingly popular and in general we’ve got a widespread support for vaccination. The education of the public’s been pretty good. Even our newspapers seem to have picked up the message that the science is in – the benefits of immunisation far outweigh the risks. And it’s really been pleasing to see that support on Talk Back Radio on newspapers where journalists are really pushing home the point that the naysayers really have got it wrong.

Porter

And what sort of proportion of people so far have proved to be, what you call, conscientious objectors – they’ve come up with a seemingly valid reason for not having their children immunised?

Hambleton

Well the rate of conscientious objectors is around about 2% and that rate has been the same for a number of years, in fact it hasn’t changed very much, even with these websites popping up here and there with whole lots of negative information. And these are people that despite scientific and comprehensive investigation just won’t accept that immunisation benefits outweigh the risks. So that group’s pretty small. The real target of this exercise are those caring parents, those, if you like, swinging voters, the undecided people who are looking for proper information and when they get that proper information from a credible source, usually their family doctor, they actually will make the decision to go ahead and vaccinate. That’s about – well it’s variable, but it’s about 8-10% of the population in various areas. Some areas we’re seeing vaccination rates down as low as 70% and we know that is a potential disaster if a case, for example, of measles is imported from overseas.

Porter

Have any parents complained that they’re having their arms twisted, that although this might be a good thing that they’re sort of being forced into doing it?

Hambleton

Well yes certainly we’ve had complaints I guess from both parents and the medical profession saying well you’re forcing us to talk to people who’ve got no interest in what we’re telling them, similarly parents are saying well why should I go to a doctor to actually achieve these aims and why shouldn’t I get access to the family tax benefit without having to go through these hurdles. And I think it’s a measure of, I guess, the government who actually is also convinced about the value of immunisation and the broader community which really supports this thrust. As we know governments often follow, they don’t lead these things and so if the broader community’s got a strong focus the immunisation is good for individuals and good for the community and that lets everyone do their job.

Porter

And have the initiatives had the desired impact – what sort of results have you had?

Hambleton

Well it’s early days, I guess in New South Wales we’ve seen the introduction of the new laws on 29th May 2013, so it’s only been a few months. We saw the changes of the family tax benefit contingent on full immunisation 1st July 2012. So if you like we’ll have those case studies and those reports available as we gather evidence but we know from international evidence and in particular in the United States that when you do put hurdles up and each time you put a hurdle up you actually cause an incremental increase in the vaccination rate. So we’re pretty sure we’re on the right track here.

Porter

Dr Steve Hambleton thank you very much. Well listening to that in our Glasgow studio was Inside Health’s Dr Margaret McCartney.

Margaret, to be fair there are no hard and fast plans to follow suit here in the UK but would it bother you if we did?

McCartney

Yes and no. I think it’s a great idea to normalise normal childhood vaccinations, the vast, vast majority of parents want the best for their child and the vast majority of parents, when they’re given good information about vaccinations, want the kids to go on and have those immunisations. So it’s good for the child, the child gets a direct benefit from being immunised, and it’s good for society because everyone in society benefits from the fact that less of these diseases can circulate within our herd. So I think there’s a double advantage there. I think the problem comes when we start to talk about compulsory vaccinations and I think this is why it’s very interesting the Australian system still had a little bit of a let out clause there with what they’ve rather – I find it quite bizarrely called – conscientious objection, of course a term that we think back to the Second World War and about pacifists. When it’s used in this context I think it’s quite unusual because most of the time the people that are deciding not to be vaccinating their children have got quite unscientific beliefs really and I think that becomes a problem because those children are not getting the benefit because of their parental beliefs and also the children are being disadvantaged in other ways potentially in a compulsory vaccination situation, perhaps a parent would be reluctant to bring the child for other medical interventions that might then doubly disadvantage the child. So the compulsory aspect I think would concern me.

Porter

Margaret, I was intrigued that the initiative seemed to have gone down very well with the Australian press, how do you think the press here would react?

McCartney

Well I hope that they would react in a similar way. I think we’ve had our hysteria over MMR, hopefully we’re over that now. I think many aspects of the press in the UK are much more responsible when they’re coming to report vaccination stories because I think they now realise that the press response to the Andrew Wakefield story caused huge amounts of damage, huge amounts of people not taking up the MMR where had they been given the facts about it they would have.

Porter

Margaret McCartney. And to be clear, although politicians have been discussing linking vaccines to benefits, there are currently no official plans to follow suit here in the UK.

Now, staying with Australia, researchers from the University of Sydney have just published a new study confirming previous research that pregnant women who see the same midwife spend less time in hospital, require less pain relief and are more likely to breastfeed and they cost the healthcare system over £300 less to boot.

A win-win situation for all concerned, yet adoption here in the UK has been slow, with the Royal College of Midwives estimating that only around one in 50 women are actually looked after by a named midwife. Cathy Warwick is the Royal College’s Chief Executive.

Warwick

It’s absolutely better for both sides and midwives love working in this way and women evaluate this type of care very highly. And it’s not just for the women who’s having a normal ordinary pregnancy, it’s also really beneficial for women who’ve got more complicated pregnancies or for women who are perhaps in more difficult social situations.

Porter

You say midwives love this sort of care, I would imagine it’s quite onerous, I mean women do not have babies according to a diary generally, they have them when they’re ready and that can be at any time of the night, any time of the week.

Warwick

That’s absolutely right, it is an onerous system but what happens is the midwives really get to know the women that they’re looking after and what they tell me is that once you know the women that you’re looking after actually the women feel very confident, so the midwives aren’t actually disturbed as much as you would think. Having said that there are some midwives who won’t want to work in this way but we will always need the other systems of care – the hospitals being run. So it provides midwives with a variety of ways of working. The problem at the moment is that when we speak to the heads of midwifery they’re constantly having to pull the midwives out of these kind of services and put them on to the labour wards to provide the care at that point of most importance. So one of the difficulties is that we just don’t have enough midwives to cover all these schemes of care.

Porter

The Department of Health issued a mandate last year saying that over the next two years – so in a year’s time from now – they wanted to achieve a number of things, one of which was to ensure every woman has a named midwife who’ll make sure she personalises one to one care throughout the pregnancy, I mean this is basically what it’s about isn’t it. So how far down that path are we?

Warwick

I think we’re a very long way for delivering on that statement in the mandate. A lot of women will be given the name of a midwife, so they will say yes I had the name of a midwife but that doesn’t mean anything. There’s no point having the name of a midwife if you can’t ring her at any time you need her.

Porter

I mean you might have the name of a doctor but you might never meet him or her.

Warwick

Precisely. So my view is that actually we’re a very long way from delivering on that statement.

Porter

Well how can somebody make a statement then – I mean this is only last year, things haven’t changed and things haven’t got better or worse much since then, it must have been fairly implausible right from the outset?

Warwick

Well the thing that has changed since that statement has been made – and I say this to be fair to people – there has been a real effort to get more midwives into the system. We’ve got more midwives being trained and we have got about one and a half thousand more midwives working in maternity services than we had. But we still haven’t got nearly enough. And a recent survey that we undertook of our heads of midwifery actually showed that 25% of them are experiencing budget cuts at the moment. So…

Porter

So they’re not allowed to take on new people effectively.

Warwick

Exactly.

Porter

How many do you think you would need if this new sort of protocol was to be implemented across the NHS?

Warwick

We would certainly need about another four and a half thousand midwives but that would be just run the system as it is. This is a very radical change, this is about taking the maternity services in this country and turning them on their head. So I think we would need to make some further investment to encourage maternity services to develop these kind of systems and eventually I believe that would save money for the health service.

Porter

But in your expert impression we’re nowhere close actually are we?

Warwick

No and the problem for us at the moment is we’re not really seeing any major effort being made to encourage the maternity services to change their systems. So we both need more midwives going into the services and we need system change. But apart from having words on pieces of paper nobody’s actually doing anything that we can see to effect that change.

Porter

Well listening to that at Westminster is the government minister for maternity – Dr Dan Poulter. Dr Poulter, Cathy Warwick’s critique there of just words on paper, no major effort, not enough midwives, all of which does suggest that the mandate was something of an empty promise.

Poulter

I don’t think that’s fair and isn’t a reflection of what Cathy just said. She initially outlined the fact that the government’s doing well by increasing by about 1500 the number of midwives working in the NHS. We inherited a position as an incoming government where there had been a historical lack of investment in maternity for a number of years. We’ve also invested in other measures, for example, putting in place a new maternity tariff which focuses much more on supporting care for women and supporting midwifery led care and care away from the medical interventions model, which has sometimes dominated too much in the past. And thirdly, we’ve made sure we invested last year – and I led this myself – a £25 million fund to support over a hundred units in the NHS to develop and improve maternity facilities and amongst those there are eight new midwifery led units. So there’s a lot of investment now going in.

Porter

But three quarters of women who go into labour are looked after by somebody that they’ve never met before, I mean that’s not a great statistic, how long do you think it’s going to take before the majority of women in the UK are looked after under this sort of caseload named midwife type model?

Poulter

The data that I’ve seen now is showing that looking at the approach of a named midwife that you have continuity of care now being provided either by a named midwife or a team of midwives then we’re seeing the majority of women now being cared for in that way. So we’ve made considerable progress towards a model that is much more personalised in care around the needs of women. And that team based approach is one that’s working well in many midwifery led units and obstetric units and one that we need to see rolled out to all women in the next few months.

Porter

Dan Poulter. And there is more on the mandate on maternity care on our website, so you can make up your own mind on how quickly we are likely to get there.

I am Dr Mark Porter and you are listening to Inside Health, coming up – why as many as half of all children and adults given asthma inhalers are not using them properly.

But first - new developments in the treatment of leg ulcers.

Around half a million people in the UK have some form of leg ulcer caused, in most cases, by an underlying problem with their circulation - typically varicose veins.

Up until recently many would simply put up with months, years and sometimes even decades of regular trips to their GP or visits from their district nurse for repeat dressings. But new guidance published by NICE looks set to change that by recommending referral to a specialist vascular clinic wherever an ulcer lasts more than two weeks.

Clinics like the one at Addenbrooke’s Hospital in Cambridge, where one patient has been battling her leg ulcers for more 30 years.

Leg ulcer patient

I’ve lost count of the times I’ve cried with them, especially at night. It’s awful. I’d rather have a baby than have ulcers and that’s saying something.

Porter

How often do you have to have your legs dressed when they’re bad?

Leg ulcer patient

When they’re bad I used to have to go down Mondays, Wednesdays and Fridays – three times a week.

Porter

It’s quite a chunk out of your week.

Leg ulcer patient

It is yeah.

Porter

And what was it like living with the ulcers at home – did you ever get infections, were they ever smelly at all?

Leg ulcer patient

Oh yes, oh horrible.

Porter

Can you describe that to me?

Leg ulcer patient

Oh it’s a horrible smell, it really is and you sit on the bus and you can smell it yourself so other people must do.

Porter

You were very aware of it?

Leg ulcer patient

Oh I was aware of it yeah, yeah.

Porter

And were others aware of it?

Leg ulcer patient

I don’t know, nobody ever said, only one – one person did and I was sitting opposite her and she said oh whatever’s that awful smell.

An ulcer is a break in the skin and there’s an underlying disease process usually, often a problem with the veins or the arteries that causes the skin to become unhealthy. There’s usually then some minor injury that may go unrecognised by the patient and this fails to heal and then gradually that small area spreads and you end up with a large raw surface that can ooze and become infected.

When the patients first notice an ulceration it’s often quite painful, so usually causes them to seek attention of either the nursing staff or the medical staff at their local practice. They then usually have a variety of dressings applied, some of which may be on an evidence base and some of which may not. The problem’s quite chronic and if it just stays static and it’s not getting any worse it’s often just managed in the community. Referral in and earlier investigation might help these people to achieve a quicker resolution of their problems.

Porter

But we’re already saying that somewhere between one in a thousand and one in a hundred people have an ulcer or have had an ulcer, I mean services like yours couldn’t deal with that number being referred into hospital so when should GPs and practice nurses who are looking after the majority of these in the early stages think about referring a patient on to you?

Hayes

Interestingly NICE have just released some guidance suggesting that anybody who’s got an ulcer that hasn’t healed within two weeks should be referred to a vascular service.

Porter

But that’s most ulcers isn’t it?

Hayes

That is all ulcers really, that is all ulcers. The reason for that is that ulcers don’t heal because unless the underlying disease process is reversed whatever dressing or treatment you apply to the top it’s not getting to the root of the problem. Referral to a vascular service will allow us to get to the root of the problem and treat the underlying disease process and then get the ulcer to heal.

Porter

So what are those underlying disease processes and how do you work out what’s going on?

Hayes

Around 70-80% of all ulcers come from venous problems and that may not be having varicose veins on the surface, you could have problems with the deep veins inside your leg. Around another 10-15% are related to the arteries – that’s the blood flow down from the heart towards the legs. And then the remainder, which is really quite a small percentage now, are due to immune diseases like rheumatoid arthritis or particular medications.

Porter

So assuming the patient comes in how do you work out whether it’s their veins or their arteries because they’d account for the lion’s share of the work that you’re seeing – and what’s the difference?

Hayes

So the first thing we would do would be a clinical assessment but quite quickly after they’ve come into our clinic we will go ahead and get a duplex scan, which is an ultrasound that looks at the direction of blood flow within the vessels. We would start off by looking at their veins and the blood in the veins should move from their toes up towards their heart in a sort of stepwise fashion as it goes through a series of one way valves, a bit like a canal boat going through a series of canal locks. Once those one way valves though cease to function the pressure in the veins goes up quite a lot and that then causes the swelling and tissue damage that we see in typical venous ulcers.

Porter

So you’ve identified the underlying cause, let’s assume it’s a problem with the blood flow either into the leg or out of the leg but what can you actively do about that?

Hayes

In the past for venous disease we only really had two options, one was bandaging and the second was surgery. Surgery is quite invasive, there’s quite a lot of complications and morbidity associated with surgery. But now in terms of interventions we’ve got a number of minimally invasive treatments that can be done either under local anaesthetic or with no anaesthetic at all in some cases to treat the veins and stop the blood going the wrong way down the veins, which is the root of most of this trouble.

Porter

So by fiddling with the veins let’s say you can encourage the return of the blood flow from the toes back to the heart effectively?

Hayes

Yeah in a more efficient fashion that will reduce the oedema or swelling in the legs and that promotes a better environment for the ulcer to heal.

Porter

Your obvious priority is to spot and fix the underlying cause of the ulcer but do you have any particular clever way of treating the sore itself – do you approach the problem differently from the practice nurse in general practice for instance?

Hayes

Our specialist nurses here obviously keep themselves abreast of the current literature and we would have access to most of the new dressings and various treatments to keep the pain down in terms of keeping on top of infection and topically applied agents that can help reduce pain from the ulcer, which is a significant problem for a lot of patients.

Porter

But the key message that I’m getting from you is that it’s not about the dressing and the care of the ulcer per se, it’s about identifying and treating the underlying cause?

Hayes

Yeah, without treating the underlying problem here the ulcer becomes chronic and that’s the problem that these patients then live with these for years.

Porter

An all too familiar scenario for the patient who has had a leg ulcer for 32 years, but since being seen by Mr Hayes at the clinic she’s had her varicose veins treated, and the ulcer has finally healed.

Leg ulcer patient

I wished I’d come here years ago but nobody ever said that there was anything else, nobody ever mentioned it. Why? I mean I don’t know how long they’ve been going – these foam injections.

Porter

Oh quite a long time.

Leg ulcer patient

Have they really? That makes you wonder why the surgery didn’t send me here before.

Porter

And how are your legs at the moment?

Leg ulcer patient

Shhhhh – we don’t say too much because they’re both healed at the moment. Yeah.

Porter

Do you take any special precautions with your legs?

Leg ulcer patient

I try not to get them banged, if I’m on the bus and somebody drops a trolley near me I said – good job that didn’t hit me.

Porter

Because that’s what you dread I suppose is…

Leg ulcer patient

It is, definitely.

Porter

…. a little tiny injury that most of us wouldn’t think twice about.

Leg ulcer patient

No, even children playing round your feet, if they catch you with a toy or they kick out at you, that can start it off.

Porter

Do you have grandchildren?

Leg ulcer patient

I’ve got six great grandchildren as well.

Porter

And they’re not allowed to play around your feet?

Leg ulcer patient

No, not round my feet. And the older ones now tell the young ones – mind nanna’s legs.

Porter

One of many happy patients at the ulcer clinic at Addenbrooke’s Hospital.

Last year the NHS spent around £800 million on asthma medicines - most of it on aerosol powered inhalers containing rescue drugs like salbutamol to relieve symptoms and/or preventers like steroids to reduce inflammation.

But research suggests that at least half the people given these so called MDI inhalers don’t use them properly, meaning their asthma remains poorly controlled – they are plagued by cough, wheeze and shortness of breath - and the NHS is wasting hundreds of millions of pounds.

Mike Thomas is Professor of Primary Care Research at the University of Southampton and Chief Medical Advisor to Asthma UK.

Thomas

When you talk to people with asthma often they’re just given a prescription and they go along to the pharmacy and get the device and use it as best they can or find somebody and watch what they do and try and imitate them. But really good practice should always involve a patient being trained in the inhaler at the point when they’re first given the inhaler and every year they should have a check of their inhaler technique because people’s technique can deteriorate over time if it’s not reinforced.

Porter

Of course one of the other problems is there are lots of different types of inhaler and if you’re shown to use one a lot of patients get changed into other medicines don’t they.

Thomas

Yeah, yeah that’s right Mark. There are lots of different inhalers, the commonest used ones are the so-called press and breathe meter dose inhalers, the ones you press and an aerosol squirts out…

Porter

You’ve got one in front of you on the table here just describe what it is for people who aren’t familiar with them.

Thomas

So it’s a cylinder with a mouthpiece and in the canister there’s pressurised gas which contains the drug, so we shake it and then we press it, when it’s pressed a jet of gas squirts out which contains the drug but you have to start inhaling just as you press, if you start inhaling too soon or too late most of the dose ends up on your tonsils and even with good technique a lot of it will end up in the mouth. And the part that’s left in the mouth drips down into the stomach, is absorbed into the circulation and so potentially causes steroid related side effects and it has no beneficial effects on the asthma.

Porter

We’re going to put together a video clip of you using this MDI inhaler to show people how to use it and you’ll be able to get that from our website but where do people go wrong – what are the common mistakes that people are making with this particular device?

Thomas

Okay. First of all the device has to be full, sometimes people don’t realise the device is empty and usually if you shake it you can hear it. Then patients have to gently exhale, then you put your lips round the mouthpiece, you press, and you start to breathe at the same time and then you mustn’t breathe too fast. With these type of inhalers the commonest problem is people go [sharp intake of breath] like that and if you do that only a tiny proportion gets in the lungs, it’s really a slow steady breath [slow steady breath]. That’s the kind of speed of inhalation you need. And there are training aids – our nurses and I, as a GP have in my office whistles and things like that that people can actually learn how to inhale properly. And it is very different, as you’ve already said, with different devices. So if people get switched to another inhaler the technique they had with the old one, which might have been good, isn’t necessarily good with the new one.

Porter

And what about research into this area, I mean if we take a hundred people who are using these sorts of devices in your experience what sort of proportion are using them incorrectly?

Thomas

Well I think the harder you look the more you find. I think probably a third have catastrophic technique and another third have poor technique and then maybe a third have quite good technique – I think that’s the kind of order of magnitude we’re looking at. Some areas are more important than others and we’re now talking about critical errors – there are some errors which are so bad that they really seriously jeopardise asthma control and I think somewhere up to a half of patients show critical errors in their technique. Interestingly not far off that number of doctors show critical errors when they’re asked to do it as well, so it’s not surprising if the doctors can’t do it themselves they’re not that good at teaching it to other people.

Porter

Is this getting better – I mean in all the years that you’ve been studying this have you seen any change? I mean it’s just incredible, I mean not only are people suffering unnecessarily with their symptoms but the sheer scale of the money that’s being wasted on drugs.

Thomas

Yeah it’s millions and millions of pounds and inhalers are some of the highest cost items on the NHS budget. There’s such pressure on NHS costs at the moment that GPs are being pressurised to prescribe the cheapest versions of everything and the cheapest inhalers are the meter dose inhalers which aren’t the easiest to use, so sometimes there are mass switches go on – the whole practice will switch every person with asthma on to the cheapest device and we’ve done research to show that if you do that then a proportion of them will lose asthma control which of course costs money – both to them as individuals and to society at large.

Porter

Professor Mike Thomas and you can watch his demonstration of how to use an inhaler properly on the Inside Health page of the Radio 4 website.

Next week we will be discussing the medicalisation of obesity – does labelling obesity a disease help or hinder the battle against its spread? And we would like to reflect your views in the debate – so please email me via insidehealth@bbc.co.uk and let me know what you think. A step in the right direction, or a step too far?